<?php
include "tema/tema1/head.php";
include "tema/tema1/menu.php";
include "tema/tema1/wrap.php";
?>


                <div class="container-2">
                	<section class="content">
                    	<h2>Formulir pendaftaran &nbsp;<small>Daftarkan diri anda gratis!.</small></h2>
                        <form action="controler/proses_daftar.php" class="form-register" method="post">
                        <h3>Data diri anda</h3>
                        <div class="registerbox">
                          <fieldset>
                            <div class="control-group">
                              <label class="control-label"><span class="red">*</span> Nama:</label>
                              <div class="controls">
                                <input type="text" name="nama"  class="input-xlarge">
                              </div>
                            </div>

                            <div class="control-group">
                              <label class="control-label"><span class="red">*</span> Email:</label>
                              <div class="controls">
                                <input type="text" name="email"  class="input-xlarge">
                              </div>
                            </div>
                            <div class="control-group">
                              <label class="control-label"><span class="red">*</span> Telephone:</label>
                              <div class="controls">
                                <input type="text" name="telepone"  class="input-xlarge">
                              </div>
                            </div>
                          </fieldset>
                        </div>
                        <h3>Alamat Anda</h3>
                        <div class="registerbox">
                          <fieldset>

                            <div class="control-group">
                              <label class="control-label"><span class="red">*</span> Address 1:</label>
                              <div class="controls">
                                <textarea class="input-xlarge" name="alamat"></textarea>
                              </div>
                            </div>

                            <div class="control-group">
                              <label class="control-label">
                                <span class="red">*</span>Kode Pos:</label>
                              <div class="controls">
                                <input type="text" name="kodepos" class="input-xlarge">
                              </div>
                            </div>
                            <div class="control-group">
                              <label for="select01" class="control-label">
                                <span class="red">*</span>Provinsi:</label>
                              <div class="controls">
                                <select name="provinsi" id="select01" class="span3">
                                  <option value="jtenggah">Jawa Tenggah</option>
                                  <option value="jogja">Yogyakarta</option>
                                  <option value="jtimur">Jawa Timur</option>
                                  <option value="jbarat">Jawa Barat</option>
                                  <option value="dkij">Jakarta</option>
                                  <option value="bali">Bali</option>
                                </select>
                              </div>
                            </div>

                          </fieldset>
                        </div>
                        <h3>Password Anda</h3>
                        <div class="registerbox">
                          <fieldset>
                            <div class="control-group">
                              <label  class="control-label"><span class="red">*</span> Password:</label>
                              <div class="controls">
                                <input type="password" name="password"  class="input-xlarge">
                              </div>
                            </div>

                          </fieldset>
                        </div>
                      <div class="pull-right">
                          <label class="checkbox inline">
                            <input type="checkbox" value="option2" >
                          </label>
                          saya telah menyetujui <a href="#" >syarat dan ketentuan</a>
                          &nbsp;
                          <input type="Submit" class="submit" value="Daftar">
                        </div>
                      </form>
                    </section>
<?php
include "tema/tema1/container2.php";
include "tema/tema1/footer.php";

?>